What’s the key treatment for runners with patellofemoral pain?

Patellofemoral pain (PFP) is recognised to be a multifactorial condition with multiple potential causes and a host of treatment options. This can leave both clinicians and runners confused and unsure about what treatment path to take. Do we use education, activity modification, rehab exercises, gait re-training or all of the above!? Do we tape, massage or manipulate, or maybe none of the above?! With lots of options but limited time and resources it helps to know what the key treatment is for runners with PFP. Recent research can shed some light on this complex topic…

In 2015 Christian Barton and colleagues published an excellent review of conservative management for patellofemoral pain the BJSM (Barton et al. 2015 – open access). This combined level 1 evidence with clinical experience and recommended a multimodal approach, tailored to the individual that emphasises the importance of education and activity modification and includes exercises to strengthen the gluteal and quads muscles. Lack et al. (2015 – open access) also reinforced the importance of including proximal rehabilitation for PFP in their systematic review. Peak muscle load on Gluteus Medius during running is approximately 4 times body weight (Lenhart et al. 2014) and so it makes a great deal of sense to strengthen the gluten for runners with PFP. There are a number of exercises that have been found to target the Glutes, we’ve included a selection of them in our free Glutes Circuit which you can download below. We’ve also written a blog about the evidence and reasoning behind this programme, which you can find here.

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We see a number of options from Barton et al.’s excellent review but we’re still no closer to knowing the priority. Research from @JFEsculier@BlaiseDubois and colleagues just published in BJSM helps to shed some light on this…

Esculier et al. (2017) randomly assigned 69 runners with PFP into 3 groups;

  1. Education and training modification
  2. An exercise programme plus education
  3. Gait re-training (mainly an increase in step rate) plus eduction

The results were surprising… all three groups improved but there was no significant difference in symptoms or function between the groups. The authors concluded,

“Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP”

So it seems, based on this research, that education and training modification are key. We’ve discussed this paper in detail on Facebook Live (we get into it from about 1:30 on the video below).

Recorded May 10th, 2017

We asked some questions in this video and @JFEsculier very kindly took time out to answer them in the comments, be sure to give him and @BlaiseDubois a follow on Twitter,

“Thanks Tom for the great summary, good comments and interesting points raised. As you mention, no study is perfect, and we sometimes have to work with available time/money when running a project. Obviously, it would have been great to screen all these runners for baseline deficits/characteristics to optimize treatment outcomes. But if you do that, you need to run 3 different RCTs for each intervention to verify if your classification criteria hold water when testing your intervention, which adds to the complexity, time and funding needed. I definitely see this as a follow-up project, which would likely require international collaboration (if anybody has any interest in this then reach out to me!). If you have money to invest, then reach out to me as well 😉

Yes, runners were still reporting some pain during running at the end of the program. Since they are group average, some runners reported no more pain in each group, and given the “intention-to-treat” analysis, some runners were considered for their baseline level of pain even at the end because they dropped out. That has to be factored in, even though we didn’t have a whole lot of dropouts.

You raise a good point regarding the exercises program. In fact, clinicians were ensuring that participants were reaching a certain level of difficulty so that they would not be able to do a third set for strength exercises. So regardless of their baseline strength, these individuals were challenged during the intervention. That is why different levels of difficulty were suggested to clinicians for the same exercise.

Like you mention Tom, I think the main take-home message from this study is that education should represent a primary component of our treatment plan in runners with PFP. Given that running injuries are largely explained by training errors, this makes total sense. That’s a fact: runners tend to overdo and push through pain. Thus, simple advice on training modifications according to symptoms are key. Clinically, my whole approach in injured runners is based on how to appropriately quantify mechanical stress and progress in an individual manner.

At the end of the day, our patients may not be part of an RCT, but they still benefit from research out there. Clinically, I rarely only educate people like our “control” arm. I also give them exercises to increase capacity and potentially decrease the risk of recurrence. And if judged necessary (mechanics contributing to persistent pain), then gait retraining is definitely an option. And why not taping, etc.

I hope this helps to answer some question. Thanks again for the post!
Cheers,
JF
The Running Clinic

Closing thoughts: As with any study we do need to be aware of the limitations and look to see if results are replicated elsewhere. This research suggests education and activity modification are important and is consistent with the key messages delivered by Barton et al. (2015). Finding what training a runner can manage in terms of symptoms and progressing towards their goals is effective for improving pain and function and should be a key part of what we do for PFP and many other running injuries. As ever though we need to tailor the treatment to each individual and recognise the multifactorial nature of running injury.

Find it achilles tendinopathy challenging to treat? See our free video series for information on injury impact, assessment and treatment. Be quick though, it’s only available for the next few days!…

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